Immediate breast reconstruction making a comeback

A patient I saw few months ago in consultation for breast reconstruction was an unfortunate example of a missed opportunity. Her surgeon, one of the more enlightened ones, had done a skin-sparing mastectomy, so the reconstruction would be a lot easier since the skin would not have to be replaced with tissue expansion. Unfortunately, the plastic surgeon she usually works with was unwilling to do an immediate reconstruction (at the same time as the mastectomy) so the skin had contracted and scarred. Had an expander or an implant been placed, this could likely have been prevented. Where did things go wrong?
There are so many decisions for a woman to make after hearing the diagnosis of breast cancer for the first time that it is tempting to simplify matters and accept the first treatment recommendation. These recommendations are often based on what is familiar and proven, which may impede willingness to adopt new approaches. Because of this, knowing all of your options is more important than ever, especially in view of recent trends in breast reconstruction.
For various reasons, mastectomy is increasingly considered over what is traditionally called “breast-conserving” treatment.  For one, lumpectomy and radiation may result in a deformed and hard breast, and surgery to correct these changes is challenging because radiated tissues don’t heal well. Another trend is the increasing numbers of women being diagnoses with a genetic trait called BRCA, in which there is a very high chance of developing breast cancer. Often it makes sense for these women to have a prophylactic mastectomy. Increasing use of the skin-sparing mastectomy, proven effective both for BRCA patients and those who already have early stage breast cancer, reframes the alternatives. And with the use of a material called “acellular dermal matrix” that forms a sort of living internal bra, reconstruction with implants at the same time as the mastectomy is producing results as good or better than radiation.
Despite these advances, a recent survey revealed that most women are not referred to a plastic surgeon for discussion of their reconstructive options even if a mastectomy is recommended. This may be because immediate reconstruction has historically had a higher complication rate than doing it on a delayed basis, so perhaps the thinking was that it can always be discussed later depending on how things go. But with the new techniques, immediate reconstruction in one stage may be the shortest route to full recovery and return to daily activities. And the results may even be better than after lumpectomy and radiation.
Consider also that traditional “breast-conserving” treatment still involves surgery (lumpectomy), and the radiation treatment involves a daily visit to the cancer center for several weeks. Other than permanently changing the way the breast looks and feels, radiation has its own set of side effects and risks. Since breast cancer typically grows slowly, there is time to learn about treatment options and make informed decisions. A fully informed decision should include information about breast reconstruction, regardless of the final plan.